Three Part Question

In [adults in cardiac arrest] does [Emergency Physician performed bedside transthoracic echocardiography] have [accurate prognostic accuracy]?

Clinical Scenario

A 62 year old male emergency patient arrives in cardiac arrest. During resuscitation he is found to have pulseless electrical activity (PEA). Several rounds of ACLS are performed with no improvement in the patient's condition. You wonder if a rapid bedside cardiac ultrasound (echocardiography) would be of any prognostic or diagnostic utility.

Search Strategy

Ovid Medline(R) 1950 to August 2011

((exp ultrasonography OR exp echocardiography) AND (exp cardiopulmonary resuscitation OR exp heart arrest OR cardiac arrest)). Limited to English and human.

Search Outcome

457 papers were found of which six were considered relevant to the three-part question.

Relevant Paper(s)

Author, date and country

Patient group

Study type (level of evidence)

Outcomes

Key results

Study Weaknesses

Niendorff et al,2005,USA

17 consecutive patients suffering 18 PEA arrests over a 6 month period at a major academic hospital. Bedside echocardiography was attempted in 7 arrests and completed in 5

Prospective feasibility study

Evaluate performance and reliability of Ultrasound assessment as an integrated part of the ACLS PEA arrest protocol

In four of five cases the nonexpert interpretation was confirmed

Extremely small sample size.
Low compliance with study protocol.
No follow up on cause of PEA arrest.
Non-Emergency Physicians with limited ultrasound training.

Blaivas and Fox ,2001,USA

Convenience sample of 169 adult non-traumatic patients arriving to a single ED over a 20-month period receiving ongoing CPR. Rapid bedside echocardiogram was performed during pulse check pauses. No patients with cardiac standstill on arrival (136) survived to leave the ED. 100% of patients presenting with asystole (65) had cardiac standstill on initial ECHO.

Small convenience sample (800 eligible pts during study).
No follow-up of survivors.
'Survival' included only to hospital admission.

Survival of patients in asystole on arrival to the ED.

No patients (65) in asystole on arrival survived. 100% had cardiac standstill on ultrasound.

Survival of patients arriving to the ED with cardiac standstill.

No patients (136) arriving with cardiac standstill on ultrasound survived to leave the ED.

Salen et al,2005,USA

Convenience sample of 70 adult non-traumatic patients arriving to four EDs over a 12-month period in either PEA or asystole. Rapid bedside echocardiogram was performed during pulse check pauses by Emergency Physicians.

Prospective observational study

Survival of patients arriving with cardiac standstill

No patients with cardiac standstill on arrival (59/70) survived to leave the hospital

Convenience sample.
Small sample size.
Resuscitation teams were not blinded to US results.
Most patients arrived with cardiac standstill.
17 of 70 subjects did not get sequential US exams.

Return of spontaneous circulation

0 of 59 patients with cardiac standstill had ROSC. 8/11 patients in PEA with cardiac motion had ROSC.

Survival to hospital discharge

Only 1/8 patients survived to hospital discharge

Salen et al,2001,USA

102 nonconsecutive adult pulseless non-traumatic patients presenting to 2 community EDs over a 12 month period. All received a subxiphoid cardiac ultrasound during CPR pauses. 53 also had capnography levels recorded.

Four patients with VWM and one patient without VWM survived to ED discharge

Comment(s)

Cardiac standstill on bedside echocardiography performed during cardiac arrest is an extremely poor prognostic indicator. Only 0.9% of patients with cardiac standstill across all six studies (3/320) survived to hospital admission. One study, Niendorff DF et al, demonstrated that non-emergency physicians with minimal ultrasound experience might carry out inadequate examinations and/or misinterpret the results. However, in the other four studies where this was examined, for all studying emergency physicians in EDs with formal ultrasound training programmes, there was excellent correlation between EP and radiologist interpretations and quick and reliable assessments of cardiac activity were obtained. Several cases of tamponade were identified at the bedside and emergent drainage permitted survival to hospital admission. Few physicians felt that the sonography interfered with, or delayed, resuscitation. All the studies had small sample sizes and the resuscitation teams were not blinded to the ultrasound results. However, the results were highly consistent between studies and cardiac standstill was almost universally associated with failed resuscitations.